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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Attachment C – Social and Health Experiences Self-Administered Questionnaire
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
Attachment C
Attachment C
Attachment C. SDOH SAQ_paper draft 4_to AHRQ.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
27,059
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
90 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
27,059
0
27,059
0
0
0
Annual IC Time Burden (Hours)
3,157
0
3,157
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Attachment D – 60 Day FRN
60 Day FRN.pdf
07/29/2020
Attachment E – Public Comments: Academy of Nutrition and Dietetics
Attachment E Academy of Nutrition and Dietetics_MEPS Social and Health Experiences SAQ.pdf
07/29/2020
Attachment E1 – AHRQ Response to Academy of Nutrition and Dietetics
Attachment E1 AHRQ Response to AND.msg
07/29/2020
Attachment F – Public Comments: Brookings
Attachment F Brookings AHRQ survey comments May 2020 - Graham.docx
07/29/2020
Attachment F1 - AHRQ Response to Brookings
Attachment F1 AHRQ response to Brookings Letter.docx
07/29/2020
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.